Monday, February 22, 2010 (1:30 to 4:00 pm) (Borough Hall Court Room)

Please provide the following information in an e-mail to the Fair Lawn Health Department:

1. Name (Last Name, First Name)
2. Parent/Guardian Name (if child)
3. Address (Street, City, State, Zip Code)
4. Telephone Number
5. Date of Birth
6. Weight (if child)
7. If this is a child, is this the child's 2nd dose of the H1N1 vaccine? (yes or no)
8. If this is the child's 2nd dose of the H1N1 vaccine, what was the date of the 1st dose? (please bring the yellow verification card with you)
9. Preferred time on the above date:

February 18
1:30 pm
2:00 pm
2:30 pm
3:00 pm
3:30 pm

Consent Form (Please print and bring with you to the Clinic.  DO NOT sign the form until you arrive in the clinic)

H1N1 Information Sheet (injection)

H1N1 Information Sheet (nasal)

E-mail all the above information to Fair Lawn Health Department.  All the information must be provided.  You will not receive a confirmation e-mail unless there is a problem with your registration.  Please show up on your requested date and time unless you are contacted by the Fair Lawn Health Department.

Parents or legal guardian must accompany child at the clinic.

Please bring proof of all vaccinations. (including the first dose of H1N1 vaccination)